Facility Evaluation Report

On April 23, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for the purposes of conducting a required 1-Year Annual Continuation. LPA was greeted and granted entry after explaining the purpose of the visit to staff. Executive Director (ED) Mandy Taylor was present to assist with the annual inspection.

During the visit, LPA conducted a tour of the facility with ED Taylor and observed all required regulatory postings in the main entry way. Facility was operating within the approved capacity. Three resident apartment buildings with three floors were inspected, along with common areas, and outdoor patios with shaded seating for residents. There were no bodies of water or obstructions. The memory care unit is located in Building 3 where LPA observed one exterior egress gate requiring a key to exit and two interior egress doors with non-operational alarms. LPA observed gnats in 8 out of 20 residents apartments, the main kitchen, dining room, and additional common areas. There were 6 small trash bags with soiled contents in hallways throughout Building 1, Building 2 and Building 3 requiring proper disposal. Deficiencies are being cited.

An audit was conducted of 20 resident files and 10 staff files. The medications and the Medication Administration Records (MARs) were reviewed. Additional interviews were conducted with residents and staff.

The Emergency and Disaster Plan (610E) was reviewed with administrator and amendments were recommended. The facility conducts quarterly disaster drills with the last one conducted on January 27, 2026, with minimal attendance.